Maternal magnesium sulfate and the development of neonatal periventricular leucomalacia and intraventricular hemorrhage.

OBJECTIVE: Neonatal periventricular leucomalacia and intraventricular hemorrhage are strong correlates of cerebral palsy. Our objective was to evaluate the effect of maternal magnesium sulfate exposure on the incidence and severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. METHODS: Nine hundred eighteen consecutive inborn neonates with birth weights from 500 to 1750 g were divided primarily into two groups on the basis of maternal exposure to magnesium sulfate. The groups were divided secondarily into two clinical groups, a physician-initiated group, which consisted of neonates delivered for maternal or fetal indications, and a preterm delivery group, which included neonates delivered as a result of preterm labor or preterm premature rupture of membranes. These clinical groups were stratified further into magnesium sulfate-exposed and -unexposed subgroups. Neonatal neurosonograms were performed on days 3 and 7 of life and described as normal or abnormal. Abnormal sonograms included any periventricular leucomalacia or intraventricular hemorrhage. Severe lesions included periventricular leucomalacia, periventricular leucomalacia with intraventricular hemorrhage, or grades 3 or 4 intraventricular hemorrhage. The magnesium sulfate groups and the clinical groups with their magnesium sulfate strata were compared for the incidence and severity of abnormal sonograms. They also were compared for maternal and neonatal characteristics. RESULTS: Maternal magnesium sulfate exposure was not associated with reduction in the incidence of abnormal sonograms when compared with the unexposed group (27% compared with 33%, P = .06). However, fewer severe lesions were observed in the exposed group (14% compared with 21%, P = .004). When clinical groups were examined, magnesium sulfate was not associated with a decrease in abnormal sonograms (adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.78, 1.52, P = .40) or severe lesions (adjusted OR 1.11, 95% CI 0.73, 1.68, P = .42). Logistic regression analyses of magnesium sulfate exposure within clinical groups controlling for the confounding effects of maternal and neonatal characteristics revealed no protective effect of magnesium sulfate exposure on the incidence of abnormal sonograms (adjusted OR 1.01, 95% CI 0.70, 1.44, P = .97) or severe lesions (adjusted OR 1.01, 95% CI 0.70, 1.74, P = .69). Within clinical groups, the preterm delivery group exhibited an increased risk for abnormal sonograms (adjusted OR 1.63, 95% CI 1.01, 2.67, P = .05) and severe lesions (adjusted OR 9.79, 95% CI 3.27, 29.29, P = .001) when compared with the physician-initiated delivery group, independent of maternal magnesium sulfate exposure. CONCLUSION: Maternal magnesium sulfate exposure had no protective effect on the incidence or severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. The prevalence of these lesions was correlated better with the clinical group of origin and indication for its use.

Cellular immunity in preeclampsia: alterations in T-lymphocyte subpopulations during early pregnancy.

T-lymphocyte subpopulations were evaluated longitudinally in 62 primigravidas. Beginning early in the second trimester, women who later developed preeclampsia showed a significantly lower proportion of T-helper cells compared with those who remained normotensive (27.0 +/- 7.1 versus 34.7 +/- 7.9%; P less than or equal to .001). The decrease in the T-helper cell count occurred several weeks before the development of preeclampsia and reverted to normal 6-10 weeks postpartum.

Nipple stimulation for labor augmentation.

A randomized, prospective study was undertaken to evaluate the efficacy of nipple stimulation with a breast pump as compared to oxytocin for augmentation of labor. The average and maximal uterine activity achieved was significantly higher in the oxytocin-stimulated group, without significant differences in the length of labor stages, cesarean section rate, Apgar scores or umbilical artery pH. Fifty percent of the patients failed to respond to nipple stimulation after 30 minutes and were switched to oxytocin. These patients experienced a more rapid rate of cervical dilation in the active phase and reached higher maximal uterine activity with oxytocin stimulation; however, the cesarean section rate was highest in this group. Nipple stimulation with a breast pump appears to be a safe and effective alternative to oxytocin for the augmentation of labor.

Correlation of Apgar scores and umbilical artery acid-base status to mortality and morbidity in the low birth weight neonate.

Neonatal mortality, idiopathic respiratory distress syndrome, and early periventricular/intraventricular hemorrhage in the neonate weighing 2000 g or less were correlated with umbilical artery acid-base status. Neonatal mortality and, to a lesser extent, idiopathic respiratory distress syndrome correlated with umbilical artery acidosis. Early periventricular/intraventricular hemorrhage was associated with low Apgar scores, but showed no correlation with umbilical artery acid-base status.

Umbilical artery creatine kinase brain-band isozyme as a predictor of neonatal periventricular-intraventricular hemorrhage.

In low-birth-weight neonates, an elevation in the percentage of creatine kinase brain-band isozyme in the umbilical artery was significantly correlated with future development of neonatal grade III and grade IV periventricular-intraventricular hemorrhage, when compared with levels in those neonates who did not show periventricular-intraventricular hemorrhage or who developed grade I and grade II periventricular-intraventricular hemorrhage (p = 0.025). In these neonates the relative levels in maternal venous, umbilical arterial, and umbilical venous samples indicated that the source of the isozyme was fetal.

Neonatal depression and birth asphyxia in the low birthweight neonate.

In 392 low birthweight neonates, acidosis as evident from umbilical artery pH 7.1 or less was strongly associated with Apgar score 6 or lower at 1 minute. However, most cases that were depressed (Apgar score 6 or lower at 1 minute) were not acidotic. Neonatal depression was most strongly and directly correlated with gestational age. Neonatal depression and birth asphyxia are distinct entities.

Serum prolactin levels during contraction stress test done by the breast pump.

Maternal serum prolactin (PRL) levels were evaluated in patients having contraction stress tests (CST) by nipple stimulation. Of 79 CSTs, 14 failed and 65 were successful. Poststimulation PRL levels in failed cases were significantly lower than those in gestational age-matched successful cases, despite longer duration of nipple stimulation in the failed cases.

Management of the third stage of labor with nipple stimulation.

Nipple stimulation was found to be a safe alternative to oxytocin in the management of the third stage of labor.

Fetal heart rate changes and uterine activity during coitus.

Fetal heart rate and uterine activity were monitored during sexual intercourse in three otherwise normal gravid women at varying gestational ages. Increased uterine activity and a variety of fetal heart rate changes, some of which are traditionally identified as ominous, were seen in most instances immediately following orgasm. An increase in fetal activity was also commonly reported by the mothers. It is postulated that coitus is equivalent to an unmonitored contraction stress test.

Silent chorioamnionitis as a cause of preterm labor refractory to tocolytic therapy.

Thirty-seven consecutive patients with singleton pregnancies in "uncomplicated" preterm labor with intact membranes suitable for tocolysis were evaluated for evidence of silent chorioamnionitis by means of maternal serum C-reactive protein and amniotic fluid white blood cell count, Gram stain, and cultures. Abnormalities in these markers of infection were found to be significantly more common in cases that were refractory to tocolysis. These cases also showed both pathologic evidence of chorioamnionitis and a significantly greater neonatal early infectious morbidity. We conclude that silent chorioamnionitis is a significant cause of "uncomplicated" preterm labor refractory to conventional methods of tocolysis.

Cerebral function monitor in the neonate. I: Normal patterns.

The cerebral function monitor (CFM) is a monitoring device which records integrated encephalograms (EEGs on slow-running paper, allowing continuous observations of cerebral activity for prolonged periods. The CFM was assessed in 49 normal neonates of different gestational ages and was found to reflect EEG activity accurately. Gestational age and sleep-wake states could be differentiated and normal patterns were defined. The establishment of normal patterns will allow further assessment of the CFM as a screening tool for the neonate at risk for cerebral hypoxic ischemic injury.

Cerebral function monitor in the neonate. II: Birth asphyxia.

The cerebral function monitor (CFM) records an integrated electroencephalogram on slow-running paper, and therefore is suited to long-term, continuous monitoring. This study describes CFM patterns of 31 neonates with birth asphyxia. Three distinct types emerged: (1) a normal pattern compatible with gestational age was uniformly associated with favorable clinical outcome; (2) a completely disorganized pattern was associated with sever injury and fatal outcome; and (3) a more subtle pattern showed reversal to a more immature gestational age. The three infants with the third pattern all survived, but with varying degrees of neurological deficit. It is concluded that the CFM can be of advantage in predicting outcome for asphyxiated neonates.

Correlation of maternal serum C-reactive protein with outcome of tocolysis.

Subclinical intrauterine infection is an important cause of preterm labor, specifically where tocolysis has failed. Fifty patients in preterm labor with singleton pregnancies were studied prospectively to determine whether the presence or absence of C-reactive protein, a nonspecific marker for infection, would correlate with success or failure of tocolysis. Of the 50 patients, tocolysis failed in 11 of 15 women with a positive C-reactive protein determination. Tocolysis succeeded in 33 of 35 cases where C-reactive protein was negative (P less than .0005). Urinary tract infection occurred in 40% of the study patients, but was not a confounding factor in the interpretation of C-reactive protein.

Terbutaline in the management of acute intrapartum fetal acidosis.

A beta 2-mimetic agent, terbutaline, was used before full cervical dilatation in 10 of 18 cases of fetal distress evidenced by fetal scalp blood pH (FSB-pH) less than 7.25. A reduction in uterine activity with an improvement in the fetal heart rate trace was seen in all the cases. In addition, a significant improvement in FSB-pH, when compared with umbilical artery pH (p less than 0.05), was noted whereas there was no significant change in the untreated cases. An Apgar score of less than or equal to 6 at five minutes occurred in two of eight untreated patients but not in any treated patients.

Prenatal diagnosis of conjoined twins.

A case of conjoined twins with open spina bifida prenatally diagnosed at the twenty-third week of gestation is presented. The early detection of this rare and unusual malformation was initiated by the observation of markedly elevated maternal serum alphafetoprotein values. Ultrasound evidence of a misshaped cephalic pole and the appearance of one fetal body on real-time ultrasound was strongly suggestive. Elective midtrimester termination confirmed the prenatal diagnosis and was followed by a benign postpartum course.

Effect of tocolysis on incidence of low birth weight.

Tocolysis was attempted in only 2.5% of 570 consecutive low birth weight deliveries in the years 1980 through 1981. The reasons for rejecting therapy in the majority of cases are discussed. Prospectively, tocolysis was attempted in only 13.8% of all patients in preterm labor, with an 82% success rate. If tocolytic therapy were not used, and a calculation made with allowance for usually acceptable false diagnosis and failure rate, the general low birth weight rate would rise minimally and insignificantly (P = 1.4). It is concluded that availability of tocolytic agents must not be expected to lower the overall low birth weight rate, although it will benefit the appropriately selected individual patient.

Prenatal diagnosis of triploidy.

Two cases of late midtrimester triploid gestation are presented. This unusual condition might be suspected in cases of first and second trimester bleeding when the uterus appears to be unusually large as estimated by the menstrual history. Early presence of gestational hypertension also points suggestively toward a triploid fetus. Ultrasound examination of the placenta typically shows multiple sonolucent areas. Confirmation of diagnosis is made by karyotyping cells obtained from amniotic fluid. The condition is incompatible with life and termination of pregnancy is indicated. It is considered prudent to follow HCG levels for evidence of persistent trophoblastic tissue.

Screening for SGA by the roll-over test.

The roll-over test (ROT) was evaluated in normal pregnant patients between 28 and 34 weeks' gestation and found to be an accurate method of screening for small-for-gestational age (SGA) infants and for preeclampsia. Patients with a positive ROT had a significant risk of SGA or preeclampsia or both. In patients with a positive ROT, the development of SGA may be further predicted by an examination of maternal prepregnancy weight and weight gain. Patients with a prepregnancy weight of 50 kg or less, total weight gain of 10 kg or less, and/or differential weight gain of 20% or less have a highly significant risk of developing an SGA fetus. In contrast, patients with a negative ROT have a significantly decreased risk for SGA and/or preeclampsia.